Provider Demographics
NPI:1558340331
Name:TRABOUT, MARSHALL M (MD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:M
Last Name:TRABOUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:18 WELLS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:NY
Practice Address - Zip Code:13026
Practice Address - Country:US
Practice Address - Phone:315-364-3388
Practice Address - Fax:315-364-5254
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY147937207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110147941Medicare PIN
NY56100TMedicare PIN
NYB82058Medicare UPIN